LandmarkRCT

MIST2

Intrapleural use of tissue plasminogen activator and DNase in pleural infection.

N Engl J Med, 2011 · Blinded 2×2 factorial trial

Population: 210 adults with pleural infection
Intervention: Combined intrapleural tPA and DNase for three days
Comparator: Double placebo or either agent alone
Primary outcome: Change in radiographic pleural opacity at day seven
Result: Combination therapy improved radiographic clearance; surgical referral 2/48 versus 8/51 and hospital stay 6.7 days shorter than placebo.

What the trial found

Combination therapy improved radiographic clearance; surgical referral 2/48 versus 8/51 and hospital stay 6.7 days shorter than placebo.

Clinical interpretation

Supports combination therapy when drainage is inadequate; single agents were ineffective. Secondary surgical/stay outcomes do not establish a mortality benefit. Assess bleeding risk and source-control needs.

Moderate certainty

Clinical Context & Relevant Topics (1)

Disease Reference

Pleural Infection / Empyema

Diagnosis and source control of complicated parapneumonic effusion and empyema with drainage, tPA/DNase and surgical escalation

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